Immunization and Medical History Form

Allied Health & Public Service

Student Medical Form

for

North Carolina Community

College

System Institutions

Student Medical Form, Physical Examination sheet, and immunizations must be submitted to your program department by ______.

The Physical Examination form on page 6 must be signed by a physician, PA, FNP or have an agency stamp (ie. Health Department).

The flu vaccine must be taken after September 1st and before October 31st. Official record of flu vaccine is required.

______

Name of Student Name of Program

______ ______

Student ID# Name of Faculty Advisor

Asheville-Buncombe Technical Community College

Allied Health & Public Service

Rhododendron Building

340 Victoria Road

Asheville, NC 28801

Revised 3/05/13
PAGE 2

STUDENT MEDICAL FORM CHECKLIST

Acceptable completed forms MUST be in the student file.

1. Report of Medical History and Family & Personal Health History (pages 3 and 4)

§Must be completed by the student and signed.

2. Physical Examination (page 6) must be completed - Statement of student’s physical and mental/emotional health must be completed, dated, and signed by physician, PA. FNP or have an agency stamp.

3. Allied Health students must provide written documentation of receiving the following vaccinations/tests (page 5):

IMPORTANT - The immunization requirements must be met; or according to NC law, you will be withdrawn from classes without credit.

Acceptable Records of Your Immunizations May be Obtained from Any of the Following (Be certain that your name, date of birth, and ID Number appear on each sheet. The records must be in black ink and the dates of vaccine administration must include the month, day, and year. Keep a copy for your records.)

High School Records - These may contain some, but not all of your immunization information.

• Personal Shot Records-Must be verified by a doctor’s stamp or signature or by a clinic or health department stamp.

• Local Health Department.

• Military Records or WHO (World Health Organization Documents).

• Previous College or University-Your immunization records do not transfer automatically. You must request a copy.

• Health care facilities where you may be employed

PPD: Tuberculin Skin Test: Must be repeated annually. If positive, chest x-ray. Treatment must be documented if necessary. Annual waiver from the local health department or health care facility must be completed annually.

Tdap (Tetanus-Diptheria-Pertussis) A Td booster must be repeated every 10 years. Tdap is given only once.

Measles (Rubeola)

Two doses measles (Rubeola) or provide serologic confirmation of immunity, unless born before 1957. (One dose on or after 12 months, second at least 30 days later. Must repeat vaccine if received even one day prior to 12 months of age.) If born before 1957, you do not need to be immunized.

Mumps One dose after12 months of age or provide serologic confirmation of immunity. History of disease is not acceptable.

Rubella (German Measles) One dose required, unless you provide serologic confirmation of immunity. History of disease is not acceptable.

VARICELLA: Chicken pox -Two doses or provide serologic confirmation of immunity. History of disease is not acceptable.

HEPATITIS B SERIES: Not required but strongly recommended.

3 doses: 1st dose, 2nd dose 1 month later, 3rd dose 5-6 months after the 2nd dose

The series should have been started before entering the clinical environment. Individuals who choose not to take the vaccine, must sign college declination form.

Flu Vaccine: Date of flu vaccine must be taken after September 1st and before October 31st.

Students should adhere to vaccine schedule for initial vaccines and updates as required by clinical agencies.

Students will not be allowed to attend clinical until immunizations are complete. Upon accumulating absences exceeding 10% of the contact hours, the student will be dropped from the class.

LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME *SOCIAL SECURITY NUMBER

PERMANENT ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER

DATE OF BIRTH (mo/day/yr) GENDER M F MARITAL STATUS S M OTHER EMAIL

PREVIOUSLY ENROLLED HERE YES NO

IF YES, DATES

PREVIOUSLY A PATIENT HERE YES NO

IF YES, DATES

NAME OF PERSON TO CONTACT IN CASE OF EMERGENCY RELATIONSHIP

ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER

The following health history is confidential, does not affect your admission status and, except in an emergency situation or by court order, will not be released without your written permission. Please attach additional sheets for any items that require fuller explanation.

Yes / No / Relationship
Cancer (type):
Alcohol/drug problems
Psychiatric illness
Suicide

Has any person, related by blood, had any of the following:

Yes / No / Relationship
High blood pressure
Stroke
Heart attack before age 55
Blood or clotting disorder
Yes / No / Relationship
Cholesterol or blood fat disorder
Diabetes
Glaucoma

HEIGHT WEIGHT

Yes / No / Year
Kidney stones
Protein or blood in urine
Hearing loss
Sinusitis
Severe menstrual cramps
sever
Irregular periods
Sexually transmitted disease
Blood transfusion
Alcohol use
Drug use
Anorexia/Bulimia
Smoke 1+ pack cigarettes/week
Regularly exercise
Wear seat belt
Other (specify)
Yes / No / Year
Jaundice or hepatitis
Rectal disease
Severe or recurrent abdominal pain
Hernia
Easy fatigability
Anemia or Sickle Cell Anemia
Eye trouble besides need glasses
Bone, joint, or other deformity
Knee problems
Recurrent back pain
Neck injury
Back injury
Broken bone
(specify)
Kidney infection
Bladder infection
Yes / No / Year
Hay fever
Allergy injection therapy
Arthritis
Concussion
Frequent or severe headache
Dizziness or fainting spells
Severe head injury
Paralysis
Disabling depression
Excessive worry or anxiety
Ulcer (duodenal or stomach)
Intestinal trouble
Pilonidal cyst
Frequent vomiting
Gall bladder trouble or gallstones

Have you ever had or have you now: (please check at right of each item and if yes, indicate year of first occurrence)

Yes / No / Year
High blood pressure
Rheumatic fever
Heart trouble
Pain or pressure in
chest
Shortness of breath
Asthma
Pneumonia
Chronic cough
Head or neck radiation treatments
Tumor or cancer
(specify)
Malaria
Thyroid trouble
Diabetes
Serious skin disease
Mononucleosis

Please list any drugs, medicines, birth control pills, vitamins, minerals, and any herbal/natural product (prescription and nonprescription) you use and how often you use them.

Name Use Dosage Name Use Dosage

* Provision of Social Security number is voluntary, is requested solely for administrative convenience and record-keeping accuracy, and is requested only to provide a personal identifier for the internal records of this institution.

Check each item “Yes” or “No.” Every item checked “Yes” must be fully explained in the space on the right (or on an attached sheet).

Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following? If yes, please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once.

Adverse Reactions to: / Yes / No / Explanation
Penicillin
Sulfa
Other antibiotics (name)
Aspirin
Codeine
Other pain relievers
Other drugs, medicines, chemicals (specify)
Insect bites
Food allergies (name)
Yes / No / Explanation
Do you have any conditions or disabilities that limit your physical activities? (If yes, please describe)
Have you ever been a patient in any type of hospital? (Specify when, where, and why)
Has your academic career been interrupted due to physical or emotional problems? (Please explain)
Is there loss or seriously impaired function of any paired organs? (Please describe)
Other than for routine check-up, have you seen a physician or health-care professional in the past six months? (Please describe)
Have you ever had any serious illness or injuries other than those already noted? (Specify when and where and give details)

STATEMENT BY STUDENT (OR PARENT /GUARDIAN, IF STUDENT UNDER AGE 18):

I have personally supplied (reviewed) the above information and attest that it is true and complete to the best of my knowledge. I understand that the information is strictly confidential and will not be released to anyone without my written consent, unless otherwise permitted by law. If I should be ill or injured or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from my (son/daughter’s) medical record to a physician, hospital, or other medical professional involved in providing me (him/her) with emergency treatment and/or medical care.

Signature of Student Date

Signature of Parent/Guardian, if student under age 18 Date

IMMUNIZATION RECORD / (Please print in black ink) To be completed and signed by physician or clinic. A complete immunization record from a physician or clinic may be attached to this form.
Last Name First Name Middle Name / Date of Birth
(mo/day/year) / *Social Security #
SECTION A REQUIRED IMMUNIZATIONS
mo/day/year / mo/day/year / mo/day/year / mo/day/year
(#1) / (#2) / (#3)
· Tdap (Tetanus-Diphtheria-Pertussis) Tdap - One dose
· Td- (Clinical agencies require one vaccine every ten years)
· MMR (after first birthday) / Titer Date & Result
Attach lab result.
· MR (after first birthday) / Titer Date & Result
Attach lab result.
· Measles (after first birthday) (Clinical agencies require proof of vaccine or titer only) / Titer Date & Result
Attach lab result.
· Mumps (Clinical agencies require proof of vaccine or titer only) / Titer Date & Result
Attach lab result.
· Rubella (Clinical agencies require proof of vaccine or titer only) / Titer Date & Result
Attach lab result.
· Hepatitis B series only OR
Hepatitis A/B combination series / Titer Date & Result
Attach Lab Report
· Varicella (chicken pox) series of two doses or immunity by positive blood titer. (Clinical agencies require proof of vaccine or titer only.) / Titer Date & Result
Attach lab report
· Tuberculin (PPD) Test Date Read
(within 12 months) mm induration
· Chest x-ray, if positive PPD Date
Results
Treatment if applicable Date
SECTION B RECOMMENDED IMMUNIZATIONS

The following immunizations are recommended for all students.

Meningococcal / Received the meningococcal vaccine? No □ Yes □
If Yes, please indicate date(s) vaccine was received (mo/day/year)
SECTION C OPTIONAL IMMUNIZATIONS / mo/day/year / mo/day/year / mo/day/year
· Pneumococcal
· Hepatitis A series only

Signature or Clinic Stamp REQUIRED:

______

Signature of Physician/Physician Assistant/Nurse Practitioner Date

______

Print Name of Physician/Physician Assistant/Nurse Practitioner Area Code/Phone Number

______

Office Address City State Zip code

** Must repeat measles vaccine if received even one day prior to 12 months of age.

*** Only laboratory proof of immunity to measles, mumps, rubella and varicella is acceptable if the vaccine is not taken. (If born before 1957, see note page 2).

PHYSICAL EXAMINATION (Please print in black ink)

A physical examination is required and must be completed in black ink and signed by a physician or clinic.

Last Name First Name Middle Name / Date of Birth (mo/day/year) / *Social Security Number
Permanent Address City State Zip Code / Area Code/Phone Number

Height Weight TPR / / BP /

REQUIRED:
Vision: Corrected Right 20/ Left 20/
Uncorrected Right 20/ Left 20/
Color Vision
Hearing: (gross) Right Left
15 ft. Right ______Left ______/ Optional:
Urinalysis :
Sugar:______Albumin:______
Micro______
Hgb or Hct ______
Are there abnormalities? / Normal / Abnormal / DESCRIPTION (attach additional sheets if necessary)
1. Head, Ears, Nose, Throat
2. Eyes
3. Respiratory
4. Cardiovascular
5. Gastrointestinal
6. Hernia
7. Genitourinary
8. Musculoskeletal
9. Metabolic/Endocrine
10. Neuropsychiatric
11. Skin
12. Mammary

A. Is there loss or seriously impaired function of any paired organs? Yes No

Explain

B. Is student under treatment for any medical or emotional condition? Yes No

Explain

C. Recommendation for physical activity (physical education, intramurals, etc.) Unlimited Limited

Explain

D. Is student physically and emotionally healthy? Yes No

Explain

• For Students Admitted to an Allied Health program•
Based on my assessment of this student’s physical and emotional health on (Date) ,
he/she appears able to participate in the activities of a health profession in a clinical setting.
Yes No if no, please explain

Signature of Physician/Physician Assistant/Nurse Practitioner Date

Print Name of Physician/Physician Assistant/Nurse Practitioner Area Code/Phone Number

Office Address City State Zip Code

*Provision of Social Security number is voluntary, is requested solely for administrative convenience and record-keeping accuracy, and is requested only to provide a personal identifier for the internal records of this institution.